II. Epidemiology

III. Associated Conditions

  1. Results in sun-downing
    1. Risk of falls
    2. Wandering Behavior in Dementia
  2. Family exhausted by required nighttime supervision
    1. Strong factor in NH placement

IV. Pathophysiology

  1. Normal sleep changes in all elderly
    1. Decrease in delta sleep
    2. Increased nocturnal awakenings
  2. Additional sleep changes in Dementia
    1. Decreased circadian cycle length
    2. Sleep cycle disconnected from environs and Time cues

V. Management: Behavioral techniques

  1. Aggressive management necessary
  2. Increase awareness of time
    1. Frequent reality orientation
    2. Access to daylight
  3. General Sleep Hygiene
    1. Restrict Caffeine and Stimulant Medications
    2. Restrict daytime naps
    3. Perform moderate Exercise early in the day
    4. Keep room cool and quiet
  4. Provide safe night-time environment
    1. Night light reduces confusion if patient awakens
  5. Reduce nighttime awakenings and potential wandering
    1. Provide nighttime Analgesic for arthritic pain
    2. Reduce Urinary urge and wetness at night
      1. Limit evening fluid intake
      2. Provide bedside commode
      3. Consider Condom catheter
      4. Use Incontinence garment
      5. Apply moisture barrier (Vaseline) to perineum

VI. Management: Medications

  1. Indications
    1. Failed response to behavioral techniques
  2. Preferred options
    1. Melatonin agents (preferred)
      1. Rozerum 8 mg
    2. Antidepressants (especially for comorbid depression or need to stimulate appetite)
      1. Remeron 15 mg orally taken before bedtime
    3. Antipsychotic Medications
      1. NOT FDA approved for Insomnia, and increased mortality risk (see Antipsychotic Medication)
      2. Zyprexa 2.5 to 5 mg orally taken 1 hour before bedtime
      3. Seroquel 25 mg orally taken 1 hour before bedtime
  3. Other agents
    1. Trazodone 50 mg orally at bedtime
      1. Risk of othostatic Hypotension and falls
  4. Adverse effects
    1. Ataxia with fall risk
    2. May worsen confusion due to Anticholinergic effects
  5. Avoid agents that worsen confusion
    1. Avoid Benzodiazepines
    2. Avoid Anticholinergic Medications
      1. Avoid Atarax (Vistaril) and Benadryl
      2. Avoid Tylenol PM
  6. Obviously avoid these preparations as well
    1. Do NOT Use these for Insomnia (listed for historical purposes)
    2. These medications were actually used for Insomnia at one time
      1. Should trigger pause in the use of contemporary medications for sleep (are we causing harm?)
      2. As with these medications, in which we now know risk far exceeds benefit
    3. Chloral Hydrate 500-1000 mg PO qhs
      1. Significant apnea risk
    4. Thioridazine 25-50 mg PO qhs
      1. Removed from U.S. market in 2005 due to cardiac arrhythmias

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